Each year, PRS produces at least one expert Video Discussion per issue. We love these videos and hope you do too; they provide a dynamic way to make education fun, accessible and multimedia.

We are very thankful for each of our fabulous Video Discussants; their efforts, expertise and willingness to step in front of the camera to discuss our field. They deserve all of our respect and gratitude. Their contributions will be watched for years to come. We could simply not provide the same level of interactivity and multimedia content without them.

While we are asking you to vote for your favorites, and will ultimately crown a "Best Video Discussion of 2014," this title will simply represent the culmination of your opinons. All of the video discussions from 2014 are important, well-done and represent a major time commitment from the surgeons you see on screen. They are all fabulous, interesting and should all be watched!

In the spirit of having a little fun, though, you will choose- by popular vote- the Best Video Discussion of 2014. In order to decide which one to vote for, we encourage you to watch all of them as they each represent hours of research and effort.

A subscription to PRS is not needed to become a registered user, or to watch the Video Discussions.

So, watch all of the great video discussions from 2014 for free and start voting today!

Civilian drones are beginning to have applications in numerous fields, ranging from delivering shipped goods, to aerial surveillance, mapping topography, disaster relief, and even natural resource exploration. Increasingly, drones are available in different shapes and sizes, and their varied abilities have garnered popularity with civilian customers and media alike, and governments are debating legislation defining the scope of their use(1).

Commercial drones afford special benefits applicable to the practice of medicine, including being equipped with advanced cameras and the ability to carry heavy loads. Companies like Amazon and Google are already pushing the envelope on how to deliver small packages quickly, safely, and efficiently using drones. It is not difficult to envision this model being adopted and improvised to deliver medications, medical supplies, even custom made 3D printed implants and biomedical devices to remote locations, over relatively long distances, and in resource constrained settings. In fact, American company Matternet is trying to do just that. In partnership with Médecins Sans Frontières in Papua New Guinea and Haiti (2), they are developing autonomous drones to help transport medicines, food, and water to areas afflicted by natural disasters. In other countries like Bhutan, where there are 0.3 physicians per 1,000 people, they are teaming up with the World Health Organization to deliver medications through inclement weather and mountainous terrain, and connect roadless rural communities to healthcare providers (3). By using drones, providers in these environments are able to save precious time and money without needing extensive infrastructure development. In addition, autonomous drones require minimal oversight, allowing providers to multiply their effects and further save on costs. Other shipping companies like DHL are already testing their “parcelcopter” to deliver medications and emergency goods daily to the island of Juist (4), and universities in England and Malaysia are utilizing drones to monitor spread of pathogens, research disease epidemiology, and track land-use changes and disease incidence in real time(5).

As we continue to find novel ways to utilize autonomous aerial drones, future applications include use by the military to carry supplies for wounded soldiers in areas of active conflict or over hazardous terrain. The lightweight and rapid maneuverability of drones combined with sophisticated cameras may someday equip physicians with tools to remotely diagnose and triage in real time to determine which patients needed medical intervention and what services would be most beneficial. In doing so, drones would not only improve efficiency in resource allocation, but also potentially save costs and valuable time.

Instead of waiting for the next technological “quantum leap” to improve patient care, what can we do better with the tools at hand? Fayezizadeh, et al, describe their impressive (but unsurprising) results using a multimodality pain control program in patients undergoing transversalis abdominis release, and find that time to resumption of oral diet was significantly shorter (versus historical controls)(1). In contrast, when pain management is viewed as a simple direct feedback system (i.e., patients are administered narcotics according to a linear pain scale), the incidence of postoperative nausea and vomiting, ileus, and length of stay goes up considerably.

As we are all aware, patients (and thus, medicine) are far from simple, and require a complex approach. Modern management strategies (e.g., Lean, six-sigma, PDSA cycles) advise us to make small, incremental changes, measure our results, and change accordingly. To quote Winston Churchill (and Frank Underwood): “To improve is to change; to perfect is to change often.” Numerous small changes have resulted in the end product of decreased length of stay, decreased narcotic use, and accelerated recovery in patients in enhanced recovery after surgery (ERAS) protocols. The authors’ results are representative of the global experience with these protocols.

Since my hospital system has initiated an ERAS protocol for abdominal surgery, we have noted a similar decrease in the utilization of narcotics, incidence of postoperative ileus, and hospital length of stay. This has been in the absence of an increase in readmissions, or added morbidity. We have subsequently started using it for our complex abdominal wall reconstruction (hernias, fistulas, component separation) with similar results. We have also changed our mesh repair technique from an inlay, to an onlay technique fixated with fibrin glue to remove trans-fascial suture pain. Like so many hospital systems, mine is undergoing a transition from “quantity” to “quality”. Some of our measures are objective, while others are patient-centered (e.g., Press-Ganey scores). Undoubtedly, instituting an ERAS system is initially more resource-intensive, and requires significant provider training … but how much does it save? And what are the gains, from a patient perspective? Will these changes be requisite, in the future, for providers and hospitals to survive in the changing environment? Finally, in an era of widespread narcotic abuse, is there a positive impact on society at large?

The immediate challenge to improving the quality of surgical care is not discovering new knowledge, but rather how to integrate what we already know into practice. Once again, this will be a situation where we will be either “flying ahead of the plane”, or “behind the plane” (to borrow project management jargon). Many plastic surgeons are already using Exparel with abdominoplasty and breast augmenation patients, with convincing results in most cases. But I feel as though we are still behind other specialties in utilizing these techniques. My orthopedic colleagues are using complex pre-surgical, intraoperative, and postoperative cocktails that have permitted outpatient knee arthroplasties for years. What will it take, and what will be the result, when we apply these protocols to our patients?

With Breast Reconstruction Awareness Day (http://www.bra-day.com) approaching this month, a timely article appears in the October 2014 issue entitled “Helping Patients Make Choices about Breast Reconstruction: A Decision Analysis Approach” by Sun et al. The authors adapt techniques which originated in business management, and which have been increasingly applied in medical decision making, to the purpose of helping a breast cancer patient decide whether and how to undergo reconstruction.

In my practice, the initial patient visit (IPV) for a patient contemplating breast reconstruction is by far the most time-consuming type of patient encounter, often extending an hour or longer. And with the inexorable pressure to cram more patients into my office hours, I have long sought the “holy grail” of time management solutions to make these visits somehow happen more efficiently through brochures, websites, adjunct counseling by staff members… you name it. And while these measures are helpful in educating patients about breast reconstruction, in the end they haven’t significantly reduced the amount of time I spend talking to a patient, and my office staff knows never to schedule a “breast reconstruction IPV” for only 15 minutes.

Perhaps the approach offered by Sun et al will change that. Although the authors never explicitly state this, their approach, with its need for computation-intensive analysis of probabilistic outcomes and use of equations with values weighted based on individual circumstances and preferences, does lay the basic groundwork for a future computerized application where patient-specific information could be entered and a Google maps-like personalized reconstruction decision guide would be returned, telling patient and surgeon the best way to get from the present office visit to the future goal of a restored breast with a minimum of complication.

"...the initial consultation is to help the patient understand my role in her recovery and to get her to see me as not only a surgeon but also a guide for her healing process. "

Yet I spend much of the visit time not in outlining probabilities but in reassuring patients, an especially difficult task given that these patients often come in already scared and anxious, still in the process of coming to terms with the reality of their recent diagnosis. And as we go over the various alternatives for reconstruction and the potential pitfalls, it can take a great deal of effort and time to help my patient keep her anxiety level in check, while also being forthright about potential complications and managing her expectations appropriately. It’s a delicate balance, and I often find that the information I say matters much less than the manner in which I say it, as well as the patience with which I listen, often at length, to my patient’s fears and concerns.

I’ve learned over time that the most productive use of the initial consultation is to help the patient understand my role in her recovery and to get her to see me as not only a surgeon but also a guide for her healing process. I try to get her to understand that proper healing requires not just my technical proficiency but also her cooperative efforts (and that of her support network) to help her body to heal well. That my technical skills as a surgeon cannot “make” her body heal and become whole again any more than a gardener can “make” a plant grow and bloom or bear fruit. Restoring a garden ravaged by disease and drought requires not just the gardener’s technical expertise but also an effort, often collaborative, to get the environment and conditions just right to promote the proper growth. To restore a women’s body requires not just my skill but also substantial efforts on her part. And I find that getting a patient to understand and buy in to this, especially if she is already afraid and anxious, takes time. And so while I welcome efforts like Sun et al, I don’t think I’ll be telling my office staff any time soon that I will be squeezing my breast reconstruction IPV’s into a crisp 15-minute encounter.

Recently, I’ve had the opportunity to consider this question since I’ve experienced both personal and professional injuries. Physicians usually apply different standards to themselves than they apply to their patients. Everyone else I know, if they are sick or injured takes time off of work – my nurse, my scrub, my husband. But because our job is to care for others, as physicians, we believe ourselves to be invincible.

everyone had his or her own tale of working at all costs – throwing up in the call-room bathroom, working with a high fever, or asking the nurse to start an IV on oneself.

As a resident, regardless of how bad I felt, I always dragged myself into work. When I spoke with my fellow residents or former residents, everyone had his or her own tale of working at all costs – throwing up in the call-room bathroom, working with a high fever, or asking the nurse to start an IV on oneself. During my training, I can recall only one instance when I left the hospital early -- as a fourth-year medical student, I came down with Rotavirus while on my pediatrics rotation and remember having both nausea/vomiting and diarrhea. After spending the entire morning in the bathroom, my chief resident finally sent me home. Similarly, I can recall stories of my father (who is also a surgeon) needing to get breathing treatments between OR cases for his asthma.

In fact I started working with my father when he was injured – he had slipped on the ice and had broken his wrist. He was in a cast for 3 months and was unable to operate during this time. When I joined his practice, I was instantaneously busy since he was unable to work. A year later, I broke my elbow while riding my bike -- I had a non-displaced radial head fracture. My practice was still young so when my orthopedic surgeon advised that I keep my elbow immobilized for 10 days, I reluctantly complied for a week. After further discussion, he conceded that I could do gentle range of motion and start operating on SMALL cases; he even specified, no breast reductions or abdominoplasties or weight bearing for 6 weeks. I did return to work (and followed his instructions).

We were able to find the pieces in the midst of the zucchini, and my father – the hand surgeon – was able to secure them as grafts to my fingertips.

Then three months ago, as I was making zucchini spaghetti on my fancy kitchen mandolin, I sliced off the tips of my thumb and long finger (as a surgeon, I was grateful that it was the radial side of my thumb and my long finger knowing that these areas are less critical for my operating skills). We were able to find the pieces in the midst of the zucchini, and my father – the hand surgeon – was able to secure them as grafts to my fingertips. A typical hand patient would have been told to keep the dressing clean and dry and to elevate the hand; I was not a typical hand patient. Since I didn’t follow instructions, I did have a little graft loss (all eventually healed well). My father told me that I wouldn’t have lost any of the graft if I hadn’t used my hand while it was healing. How does one do that? I’m used to washing my hands umpteen times in a single day.

In the past, I have treated my running and athletic endeavors the same way that I have treated surgery – I have always learned to run through the pain whether it was plantar fasciitis, a strained muscle, or hip pain. I was able to get away with this approach until a few years ago when I had my first stress fracture. At that point, there was no way for me to continue to run through the pain, and I had to take time off from running – 4 weeks after the first stress fracture 6 weeks after the second. I was forced to take time off again following a recent hamstring injury. I injured my hamstring while running – the pain was so severe that initially I had difficulty walking. Nevertheless, as soon as I started to feel better, I started running again – probably too soon and promptly reinjured it. This time, I dutifully rehabbed the injury – took time off from running, then after the pain had disappeared started gentle stretching and cross-training with swimming. I followed instructions so well that I didn’t run for five weeks despite having an upcoming relay race (Hood to Coast in Oregon).

As caregivers, it is difficult to acknowledge our vulnerability – not only for ourselves but also for our patients.

So, why do I have this compulsion to keep working or running despite the effects to my well-being? When we watch professional athletes, many of them will take time off because of an injury – OKC Thunder player Russell Westbrook was sidelined during NBA playoffs for example. Similarly, as a physician, when I discuss upcoming procedures with patients, I routinely advise them how much time they may need to take off of work, how long before they can work out, and how long they may require someone to help them at home. And as they recover from surgery, when they ask about resuming activities, I always urge them to listen to their bodies. They can gradually start to increases activities but should pay attention if “something doesn’t feel right, ” and “listen to your body.” While it may be easy for me to give advice, it is far more difficult for me to follow this advice.

The easy answer is that we are the caregivers. As caregivers, it is difficult to acknowledge our vulnerability – not only for ourselves but also for our patients. Telling a patient that you have to cancel surgery – even if it is because the surgeon is sick or injured still results in disappointment and frustration for the patient. When I broke my elbow many years ago, I had to cancel a bilateral DIEP flap – despite the excellent reason for needing to reschedule, my patient’s initial response was negative. So, I have had it ingrained in me that I don’t cancel patients, ever.

... we are human and not invincible.

The other part of the equation is the guilt I feel for having to cancel on any commitment – whether it’s to myself or to others. With running, I beat myself up if I skip a day – saying that I’m lazy; and I take the same approach if I have to change my work schedule for a personal reason. I have had asthma since childhood. Typically, when I have a severe episode, it will rapidly progress to bronchitis. After having a particularly bad weekend, I spoke to my father on Sunday evening about our DIEP flap for the next day. My dad said, “are you sure that you’re ok for tomorrow?” I responded, “ Of course I am, I’ve never cancelled a surgery before for an asthma attack.” He said, “maybe you should consider it, you don’t have to work if you’re not feeling well.” At that point I realized that I had never had permission to think of myself and how I felt. Now, I had permission to acknowledge that I may not be 100% upto a task.

Usually, when I’ve had an athletic injury severe enough to keep from running, I have been told not to run; when I have a personal illness, as physicians, we rarely obtain “permission” not to work – even on days off, patients still have needs and will still call. Struggling to take care of our patients and ourselves is a balancing act that many of us are still trying to navigate. Nevertheless, we must all admit that we are human and not invincible.

After seeing the proposed TOC for the June issue of PRS, I was intrigued by the title of Lopez, et al.’s “the Impact of Conflicts of Interest in Plastic Surgery: An analysis of Acellular Dermal Matrix, Implant-Based Breast Reconstruction”. I have always wondered whether certain biases influence our decision-making in medicine. Most of us will deny that we are influenced by external factors and the potential for financial gain when we treat our patients. But I’m not sure that this is always true. And it can be far more complicated than we realize because there may be many more subtle conflicts of interest in our everyday lives.

"While it is tempting to say that the financial rewards we obtain from either patients or industry are our “treats”, I don’t believe that it is so simple."

Last year, I adopted a second lab, Scout. Scout and I have been taking additional obedience training classes – mainly because he is my problem child. For those of you who don’t have dogs, most of the training involves rewards (treats) for good behavior. If he looks at me when I ask, he gets a treat; if he doesn’t growl at my neighbor, he gets a treat; if he sits and stays, he gets a treat. While it is tempting to say that the financial rewards we obtain from either patients or industry are our “treats”, I don’t believe that it is so simple.

Lopez’s article defines a medical conflict of interest as, “a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain).” In the article, conflicts of interest can take many forms -- recipient of grants, royalties, stock options, member of speaker’s bureau or advisory board, and employee or consultant status; according to the article, most reported conflicts of interest were being a consultant or members of a speaker’s bureau.

Over the past few years, I have incorporated the use of ADMs into my breast reconstruction practice. However, I have always had concerns about the complication rates in my patients and in the literature. I do believe that in the right patient and under the right circumstances, their use provides a huge benefit. Nevertheless, I have always been suspect of the studies that many of the different sales representatives have shown me about the use of ADMs; invariably, these studies report low or comparable complication rates when an ADM is used and when no ADM is used.

"While this article discusses one type of conflict of interest, I started to consider the other types of conflicts of interest that each of us grapples with on a daily basis."

My concerns were validated after reading this article. In Lopez et al.’s analysis, they found that there was a lower complication rate with the use of an ADM if a conflict of interest was reported; however, when no ADM was used, studies with and without conflicts of interests reported similar complication rates. This finding correlates with the author’s initial hypothesis that industry funding of research is more likely to be associated with pro-industry findings.

While this article discusses one type of conflict of interest, I started to consider the other types of conflicts of interest that each of us grapples with on a daily basis. One example would be the young surgeon who chooses to operate on a borderline surgical candidate – a woman, who is a poor surgical candidate, is referred for breast reconstruction from a general surgeon whose last patient you saw was also not a surgical candidate. You may choose to offer this patient surgery where as two weeks ago you may not have offered her surgery because you don’t want to lose this general surgeon as a referral source or because it is a “slow” week.

"The reality is that we have potential conflicts of interest every day in our lives – both personal and professional."

Another type of conflict of interest is at the heart of our specialty. We routinely perform elective surgical procedures for money, and on the most basic level, every cosmetic patient is a potential conflict of interest. Once again, not all patients will be ideal surgical candidates. For example, several weeks ago, I was supposed to perform an abdominoplasty on a woman whose past medical history was only significant for gestational diabetes. On her pre-operative bloodwork, I discovered that her blood sugar was over 350. She argued with me to go ahead and proceed with surgery; I chose to cancel her surgery, refunded her money, and referred her to a primary physician to work-up and treat this new diagnosis. I had counseled her that we could perform her elective surgery once her medical issues were well-controlled and that I was trying to do what was in her best interest; however, I have to admit that as she cried and begged, it was tempting to say “ok, let’s do surgery.”

The reality is that we have potential conflicts of interest every day in our lives – both personal and professional. As surgeons who strive to care for our patients and use evidence-based medicine to help our clinical decision-making, we have to be aware of these conflicts so that we can appropriately interpret the data. We will never be able to completely eliminate these conflicts of interest. Rather, we have to be aware of them and do our best to analyze our motives if there is ever any doubt.

On this Fathers Day, I’ve had the opportunity to reflect on the past seven years of working with my father. In 2007, I joined my father in private practice in Oklahoma City. Many have assumed that I pursued a career in plastic surgery to follow in my father’s footsteps.

"Almost in defiance of these assumptions, I pursued a fellowship and then joined an academic practice in a different city."

The actual story is that while as a young girl I had dreamed of becoming a surgeon, that dream turned to one of becoming a writer while I was in college – my father believed that journalism was an unstable career choice, so I was told to pursue an alternative. Then, when I did decide on pursuing plastic surgery, my father actually discouraged me from a surgical career.

The same assumptions repeated themselves after I completed my plastic surgery residency. Many of my surgical attendings and fellow residents assumed that I would join my father in private practice in Oklahoma City. Almost in defiance of these assumptions, I pursued a fellowship and then joined an academic practice in a different city.

"My patients and others always ask me about what it is like working with my dad."

After a few years, I did move back to my hometown, and I did join my father in private practice. Initially, I worked under his direction – he had fallen on the ice during the winter and broken his wrist, making him unable to operate for three months. All of his patients (who were already scheduled for surgery) were given the choice of a referral to another plastic surgeon in the community or me. Then, in the early years, we worked together on many of the larger surgeries in plastic surgery -- breast reductions, breast reconstructions, abdominoplasties, etc. As time wore on, he stopped performing those larger, more tedious surgeries and now limits his practice to primarily hand and face. And we stopped working together for most surgeries. However, he still assists me on all of my free flaps, which are primarily DIEP flaps. During this time, I have been able to share with him the new microsurgical techniques that I had learned during my fellowship.

"The good part of working with your father is you always have a support system"

My patients and others always ask me about what it is like working with my dad. I’ve always said that it is both good and bad. I remember the first free flap he and I did together in 2007. He tried to assist me under the microscope. Both of us became frustrated with one another because each of us wanted to be in charge. After that experience, he does not assist me under the microscope anymore. We had a similar degree of mutual frustration with the first free fibula that we did together too.

The good part of working with your father is you always have a support system – he has told me that he worries for me and becomes just as stressed as I do about having a successful outcome when I perform complicated microsurgical cases. The bad part is that while I am also a surgeon, I am his daughter – like many fathers, he believes that his way is right, and this sometimes applies in the operating room as well. As surgeons, we have come to believe that we are the leaders in the operating room, and while it takes an entire team to perform a surgery, there is ultimately one person with the primary responsibility – the surgeon. As a daughter, I have to listen to my father; as a surgeon, I may not want to.

"I had a really good time working with him last week on this surgery. Part of the joy came from the excitement in the preparation for the surgery"

Now that we have worked together for seven years, we have an established routine, and we rarely have father-daughter conflicts. He primarily will assist me on my DIEP flaps only, unless I ask him to work with me on other surgeries. Recently, I did ask him to assist me on a closed rhinoplasty because he has a great deal more experience with this procedure. My father particularly loves this operation, and I think that he was excited that I asked him to help me.

I had a really good time working with him last week on this surgery. Part of the joy came from the excitement in the preparation for the surgery – reviewing photos, ensuring that we had all of the necessary instruments in our new surgical facility, and discussing the surgical goals. The actual surgery was fun too – I think that I’ve learned that I have to allow my father to be my father, even when we are working together, and I don’t have to be the daughter who has something to prove.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 like most legislation affecting healthcare is extremely complicated. Electronic information identifying patients is protected by HIPAA as well as provisions in the Health Information Technology for Economic and Clinical Health (HITECH) Act. On September 23 2013 the HIPAA Omnibus final rule) http://www.hhs.gov/ocr/privacy/hipaa/administrative/omnibus/) became effective, which extended HIPAA requirements to Business Associates (BA) of Covered Entities (http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/index.html) . These changes to HIPAA mean that service providers are required to follow HIPAA regulations to legally handle PHI. One of the many challenges facing the modern plastic surgeon is how to insure that the vast array of digital patient information remains confidential, and protected from unauthorized access.

Like many of our colleagues, on a daily basis I take photographs with my digital camera, send text messages to residents about patients (which also may contain photos), send emails about patients, and access the electronic medical record.

At my institution we use a HIPAA compliant smartphone app for messaging, and this got me thinking about whether other technologies in common use are HIPAA compliant.

Apple Facetime

A letter in PRS (March 2012 - Volume 129 - Issue 3 - p 562e-563e<http://journals.lww.com/plasreconsurg/toc/2012/03000>) highlighted the use of Facetime as a mode of video consultation. Whilst Apple states that Facetime calls are encrypted (https://www.apple.com/iphone/business/it/security.html), this encryption does not satisfy HIPAA requirements because Apple hold the encryption key, and the data is transmitted through their servers. Under the regulations, Apple is classified as a 3rd party with access to EPHI, and therefore would have to sign a Business Associate Agreement (BAA) to meet compliance. As Apple do not sign BAAs for this purpose, Facetime cannot be considered HIPAA compliant.

Dropbox

Dropbox is not HIPAA compliant. As part of the HIPAA security rule technical controls, the ability to audit who has accessed electronic protected health information (ePHI) is required. Dropbox does not have any audit controls in place to allow a review of who accessed information that is stored on Dropbox. Without auditing, it is not possible to determine which individuals accessed ePHI. Additionally, file metadata (http://en.wikipedia.org/wiki/Metadata) is visible to Dropbox, which doesn't meet HIPAA requirements.

Google Apps for Business

In February 2014, Google announced that their cloud based platform (Gmail, calendar, Drive) would be HIPAA friendly, and that they would support BAAs. However, it's important to remember that the BAA refers only to the business version of these commonly used services. The free individual user versions do not offer the same audit and security capabilities.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the May issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Effects of Hypotensive Anesthesia on Blood Transfusion Rates in Craniosynostosis Corrections." by Fearon et al.

Conclusions: We were unable to find any significant difference in transfusion requirements between hypotensive and standard anesthesia during craniosynostosis corrections. Considering potential benefits of improved cerebral blood flow and total body perfusion, surgeons might consider performing craniosynostosis corrections without hypotension.

The full article will be published with the May 2014 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

It had been two weeks now. Her implant was gone and she was looking at me from where she sat on the exam table. Even though she had known it could happen, had signed the consent form indicating I’d told her that this could happen, I could tell from the look she was giving me that she never expected it would actually happen.

I knew better, but I admit I hadn’t expected it would happen either, especially to her and now. Several months had passed since the implant was placed. She didn’t smoke, never had radiation for her breast cancer, and had done everything I asked. She’d been doing well and at her last routine visit a month ago I’d congratulated her on making it through the reconstruction gauntlet. Back then, she had sat on that exam table looking at me with a smile of relief and gratitude.

But that was then. Some time after that visit I got the call she had redness and some drainage. During the ensuing flurry of evaluation and discussion, I had her focus on making sure the infection didn’t get worse and threaten her health. And with that in mind, we decided the implant couldn’t be salvaged and had to come out. The explantation had gone smoothly and she completed her antibiotics. She was doing well, except….

“So what’s next?” That’s what her look now seemed to ask me. At her initial consultation, she’d been adamantly not interested in autologous reconstruction. She didn’t want the added scars, the possible donor site morbidity, etc. And the last few weeks hadn’t changed her mind about that. But she also wasn’t willing to accept a bra prosthesis as a long-term solution. She wanted to try the implant again. I didn’t think that was a good idea without better tissue coverage. We were at an impasse.

In the end pressed for time, I punted the question to a future visit, telling her we had to wait a few months anyway. I’m sure it wasn’t the most satisfying answer for her and the lack of a clear plan left me in a frustrated mood. I was still feeling that sour mood when a few days later I found myself at the Plastic Surgery Research Council meeting in New York City.

"Having the opportunity to speak face-to-face with the surgeon and pick his brain about the flap made me feel a lot less sour about missing time with my family"

Even though I’ve always enjoyed going to these and other plastic surgery meetings, it’s been getting harder and harder each year to go, what with the squeeze of ever increasing expectations for clinical productivity and family commitments. As I wandered among the scientific sessions, my phone was a constant distraction as it buzzed with photos of my young daughters that my loving wife was sending from their weekend trip away along with text messages like “Check out what you’re missing!”

Then, looking up from my wife’s latest salvo of guilt-laden cuteness, I saw a poster entitled “The Lateral Intercostal Artery Perforator (LICAP) Flap for Outpatient Total Breast Reconstruction”. Forgetting my family (for just a moment), I immediately thought of my patient and went up and started chatting with the authors who were standing there. This flap wasn’t something I’d thought of during my patient’s visit earlier that week, and it was wonderfully fortuitous and timely to come across this particular poster. Having the opportunity to speak face-to-face with the surgeon and pick his brain about the flap made me feel a lot less sour about missing time with my family.

We had a great discussion and I left the poster looking forward to seeing my patient again. Even though I couldn’t be sure, at least I had a feasible option to offer that I thought she just might be willing to accept. Whatever frustrations and qualms I had about coming to the meeting had melted away. I stood there among the poster presentations and all the exciting and innovating work around me and felt a reinvigorated sense of optimism. Now this is why I go to meetings like the PSRC!

I took a selfie among the posters and shot it back to my bemused wife with the message “Hey, check out what YOU are missing!”

I first want to congratulate the authors on a fascinating application of technology to resident education. Two aspects of the study, microsurgery and education, are topics very dear to me. Microsurgery is unique in that simulators are likely to play a greater role in the acquisition of surgical skills with the increasing role of patient safety. In addition, with the increasing transparency and standardization of graduate medical education, having a “video record” of a given trainee’s (or practicing physician, in the instance of MOC) performance could feasibly become a standard evaluation tool. My only suggestion is that microsurgical performance in the operating room is rarely as straightforward as sewing two vessels together, end to end. Vessel exposure, alignment and positioning, and design of the vessel inset all have relevance to the success of a given anastomosis (and hence flap). Thus, I do not think it is sufficient to just assess a given trainee’s facility with device handling and suturing. At my previous position, we trialed an in situ device for skills training, and we varied scenarios (end to end, end to side, vessel mismatch). I suggest that such varied clinical scenarios become part of the microsurgical skills training curriculum.

I have a second reason for addressing this article. Using technological aides as a “virtual presence” is here to stay, and we will either be early adopters, or “late laggards”. For instance, “virtual patient visits,” vis-à-vis phone calls, secure emails, or remote patient access to his or her own medical record rose from 4.1 million in 2008 to 10.5 million in 2013. Moreover, you can obtain an MBA, PhD, Bachelors and/or Masters degree, and professional degrees (law school, veterinary school) entirely online. You can even become a Count of Sealand, or a Lord in the Scottish Highlands with a simple online application. The Plastic Surgery Education Network also offers updates and technical pearls with regard to surgical techniques and topics in plastic surgery.

Recently, planning started for a Global On Line Fellowship in Head and Neck Surgery and Oncology. The goals for the undertaking are noble: outside of major medical centers, care for head and neck cancer is fragmented and irregular, and it is not realistic to expect every practicing surgeon or oncologist to take a year (or more) from their personal and professional lives to obtain specialized training. The vast majority of any medical education is based on knowledge acquisition, and I suppose there is no reason you can’t learn that from a book, online lectures, tests and/or remote tutorials. But what about surgical skills acquisition? To date, there are no disciplines requiring a component of manual dexterity, which can be completed solely online (e.g., auto mechanic, aircraft pilot, nursing, scuba diving). The standard for this new program is a two-month “observership” at a pre-determined high volume center for head and neck oncology. Is this reasonable? Prerequisites for the program include:

1. A minimum of five years of surgical training and Board certification or its equivalent in their country of residence, in the specialty of general surgery, otolaryngology, plastic surgery, maxillofacial surgery, or similar field.

2. Certification and letter of support from the head of the institution where the candidate conducts his/her clinical activities indicating a commitment by the candidate to the specialty of head and neck surgery and oncology.

3. A complete list of operative procedures performed during the preceding year showing a significant proportion of head and neck cancer/tumor cases, (over 50%) where the candidate was either the operating surgeon or first assistant.

4. Commitment of the candidate to complete the Fellowship by a letter of intent and commitment for the required time and effort to complete the Fellowship.

Is board certification, and a “significant proportion of head and neck cancer/tumor cases” a reasonable surrogate for traditional, apprenticeship-style learning? If you complete this program, does that mean that you are a fully-trained head and neck surgical oncologist? I would anticipate that the degree/certificate does not confer some type of equivalency for US Medical Boards, such that foreign medical graduates could obtain a US license. Regardless of the details, it is clear that the global medical training paradigm is changing. As a specialty, to what extent do we want to adopt these changes? In addition, how can existing (and evolving) technologies be leveraged to improve our specialty and our patients’ lives?

PRSonally Speaking invites you to discuss controversial or popular papers from the pages of PRS in these periodic blog posts. In order to open the conversation to the entire Plastic Surgery community, the hot topic articles featured as sneak peeks in PRSonally Speaking last month and the articles featured in press releases will be FREE for two months as a special promotion.

Help us get the word out by inviting non-subscriber colleagues, students and residents to read these FREE hot articles and share their comments below.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the April issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Treatment of infantile haemangiomas with propranolol - clinical guidelines" by Szychta et al.

Introduction. Infantile haemangioma (IH) is vascular tumour and requires treatment in lesions manifested by potentially dangerous symptoms. Several publications reported that involution of IH could be accelerated by propranolol, but used only invalidated subjective measures of assessment. We aimed to validate objectively the aesthetic results after propranolol treatment for IH, and to produce protocol of therapy, including optimal timing for introduction, pre-treatment preparation, dosage, frequency of visits, duration and patient safety.

Methods. For the non-randomized comparative cohort study we enrolled 60 patients treated with propranolol. Medical 2D photographs, taken pre- and post-treatment, were analyzed subjectively by three plastic surgery consultants and objectively with computer program. Aesthetic results were analyzed using the following parameters: subjective overall outcome, subjective colour fading and objective colour fading. Reliability of subjective and objective methods were quantified and compared, as described with accuracy and repeatability. Volumetric parameters were obtained from 3D scans taken pre- and post-treatment and analyzed objectively with computer program. Numerous patients' data were recorded from the medical notes.

Results. Our study proved high efficiency of propranolol in treatment of IH, as assessed with the objective measures for the first time. We outlined optimal protocol of treatment, including introduction, dosage, duration and cessation of therapy.

Conclusions. Propranolol is an effective, well tolerated and safe first-line treatment for proliferative haemangioma. Therapy should be commenced early, continued with the target dosage of 2mg/kg/day in 3 divided doses through proliferative phase of IH and stopped gradually.

The full article will be published with the April 2014 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the April issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "In vitro and in vivo investigation of the influence of implant surface on the formation of bacterial biofilm in mammary implants" by Jacombs et al.

Abstract

Background: Capsular contracture remains the most common complication following breast augmentation surgery. There is increasing evidence that bacterial biofilm on the implant surface is responsible for initiating inflammation leading to capsular contracture in the majority of cases. We have used pooled data from the in vivo porcine model of capsular contracture to determine if the interaction of bacterial biofilm with smooth and textured implants independently determines progression to capsule formation. In addition, we performed an in vitro experiment to investigate the rate of bacterial growth and adhesion on textured versus smooth implants.

Methods: A total of 16 adult female pigs had 121 breast implants inserted. Of these, 66 implants - 23 smooth and 43 textured - were inoculated with a human strain of Staphylococcus epidermidis and received no other treatment. The implants were left in situ for an average of 19 weeks, after which Baker grading was performed and implants retrieved for analysis. Analysis included scanning electron microscopy (n=66) and determination of the number of infecting bacteria in capsules (n=23) and implants (n=19) by quantitative polymerase chain reaction. For the in vitro analysis 14 sterilesmooth and 14 sterile textured mini implants were incubated separately in 10% tryptone soy broth (TSB, Oxoid) inoculated with 5.8 x 106 colony forming units of S. epidermidis. Samples were removed at 3 time points (2, 6 and 24 hours) for both quantitative bacterial analysis and imaging using confocal laser scanning and scanning electron microscopy.

Results: At explantation, there was no significant difference (p=1.0) in the presence of capsular contracture (Baker grade III and IV) between smooth implants (19/23, 83%) and textured implants (36/43, 84%). Biofilm was confirmed on 60 of the 66 capsules. Capsules from smooth and textured implants had the same number of infecting bacteria (3.01x108/gram for textured versus 3.00x108/gram for smooth). Interestingly, there were 20 fold more bacteria attached to the surface of textured implants when comparedwith the surface of smooth implants (1.18x108/gram for textured versus 5.75x106/gram for smooth). For the in vitro analysis, the surface of textured implants showed 11x, 43x and 72x more bacteria at 2, 6, and 24 hours respectively when compared with smooth implants (p<0.001). These findings were confirmed by imaging analysis.

Conclusion: These results show that both in the porcine model of breast implant contracture and in vitro analysis, textured implants develop a significantly higher load of bacterial biofilm in comparison to smooth implants. Furthermore, in vivo, once a threshold of biofilm forms on either smooth or textured implant surfaces, there seems to be an equal propensity to progress to capsular contracture. The significantly highernumber of bacteria attached to the surface of textured implants is a novel finding and further investigation is warranted to delineate the host response to this higher bacterialload at the implant/tissue interface.

The full article will be published with the April 2014 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

PRSonally Speaking invites you to discuss controversial or popular papers from the pages of PRS in these periodic blog posts. In order to open the conversation to the entire Plastic Surgery community, the hot topic articles featured as sneak peeks in PRSonally Speaking last month and the articles featured in press releases will be FREE for two months as a special promotion.

Help us get the word out by inviting non-subscriber colleagues, students and residents to read these FREE hot articles and share their comments below.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the March issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "The Graft to Capacity Ratio - Volumetric Planning in Large Volume Fat Transplantation" by Del Vecchio et al.

Background: Variability in large volume fat transplantation has been linked to technique. Meanwhile, the recipient site volume and its relation to the volume of grafted fat has been relatively overlooked. Graft to capacity concepts are evidenced inother soft tissue transplantation procedures such as skin and hair transplantation. We define the Graft to Capacity Ratio as the volume of grafted fat in relation to the volume of the recipient site. We postulate its theoretical limits, and empirically analyze itspotential clinical importance in large volume fat transplantation.

Methods: Thirty cases of large volume fat transplantation to the breast were reviewed. All patients underwent pre-operative quantitative volumetric analysis using threedimensional breast imaging and underwent large volume fat transplantation using the large syringe technique. The volume of fat transplanted into each breast at the time of surgery was noted. Quantitative volumetric breast imaging was repeated 12 months postoperatively.

Results: The average Graph to Capacity Ratio was 117% with a standard deviation of 22%, consistent with deduced theoretical limits. Cases where the Graft to Capacity Ratio exceeded one standard deviation demonstrated lower percent volume maintenance. Cases where the Graft to Capacity Ratio was lower than one standard deviation appeared to demonstrate higher percent volume maintenance. Univariate linear regression of percent volume maintenance as a function of Graft to Capacitydemonstrated a significant inverse relationship.

Conclusion: The Graft to Capacity Ratio appears to be a relevant variable in percent volume maintenance outcomes and may be useful in establishing consistency in large volume fat transplantation.

The full article will be published with the March 2014 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the March issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

.

This week we present the introduction to "A Process for Quantifying Aesthetic and Functional Breast Surgery: II- Applying Quantified Dimensions of the Skin Envelope to Design and Preoperative Planning for Mastopexy and Breast Reduction" by Tebbetts et al.

Abstract

BackgroundA previous submission defined methods to objectively define nipple position and vertical and horizontal skin excess in mastopexy and breast reduction1. This paper defines a set of second stage processes for quantified design and operative planning for skin envelope modification.

MethodsA skin envelope modification procedure was designed and quantified based on the quantified amount of vertical skin excess. This process was applied in 124 consecutive mastopexy and 122 consecutive breast reduction cases. Average follow up was 4.6 years (range 6-14 years).

ResultsAll cases were assessed, planned, and executed applying the processes in this paper. No patient required nipple repositioning. Complications included excessive lower pole restretch (4%), periareolar scar hypertrophy (0.8%), hematoma (1.2%), areolar shape irregularities (1.6%). Delayed healing at the junction of vertical and horizontal scars occurred in two reduction patients (2/124=1.6%), neither of which required revision. Overall reoperation rate was 6.5% (16/246) for patients in the first 5 years of the study, and decreased to 1.6% for patients from year 6 through year 14.

The full article will be published with the March 2014 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

The beginning of a new year can be a time for reflection and calm after the chaos of the Holiday Season. For many surgeons, this chaos extends beyond the usual flurry of activity surrounding families and the holidays -- many patients choose to have surgery at the end of the year for many different reasons.

My husband, Trevor and I, had planned a trip at the end of the year to relax after this chaos – we were going to Ecuador to go climbing. Vacations where we go climbing or hiking have no cell phone access, no patients, and offer the ability to push your body to the limits – these types of trips have always been the most therapeutic vacations for me.

However, I have to admit that my preparation for this trip was the least prepared that I have ever been for a vacation. Normally, I plan, and plan, and plan – I buy travel books. I read them. I highlight the interesting points, and I make lists – lists of what we’ll do, lists of what we need, and lists of what we’ll eat. I would explain to my husband that this intensive planning was part of the vacation – the time I spend planning and surfing the Internet before bed was a part of my relaxation and allowed me to anticipate our trip. Essentially, I planned for a vacation in the same way that I would plan for a complex surgery – I would read, make lists, and strategize. Well, for this trip, the time I spent was at a minimum mainly because there just wasn’t enough time in the day.

In some ways this approach was liberating. I packed quickly, forgot many things – had to buy a few things that were forgotten -- but still had a great trip. While this approach usually doesn’t work well in the operating room, I do believe that it was the right approach for a vacation and I might try it again. As surgeons, we plan all of our activities, and we analyze our results. By looking at our outcomes, we hope to be able to improve our results and minimize our complications.

A perusal of this month’s PRS has many lists – Nahabedian’s list of high risk patients for implant-based breast reconstruction – obese, smokers, multiple comordities; lists of what patients look for in a cosmetic surgeon – experience, referral by someone we know, cost; and lists of which patients get readmitted to the hospital after surgery – those who are obese or who have multiple comordities. While these lists allow us to become better surgeons and provide better care to our patients, other aspects of being a good physician may be less easy to quantify.

As a medical student, I was attracted to surgery because of the procedural nature of the field. I became a microsurgeon because I loved the challenge of reconnecting tiny vessels and watching a piece of dead tissue spring to life with pulsations and blood flow. But that is not the only reason that I enjoy my job today. The things that give me the most joy about my job today are the patients – the human aspect of the specialty, not the lists that I make of how to do a surgery (although a well-executed surgical plan is like a beautiful ballet). We have to take the time to remember the patients who will tell you that they feel blessed that you are their doctor or the ones who tell you how you have changed their lives. I love the way that my patients can share with each other too -- the ones who will show their breasts to fellow women with breast cancer, the ones who will leave anonymous Christmas envelopes of cash for those who are less fortunate.

As a student who was considering a career in surgery, my father had said to me, “Surgery is not easy. It becomes very stressful to hold the knife.” Yes, the actual act of doing surgery is extremely stressful – the risks, the complications, the consequences of one misstep -- hence the lists that we make. But the joy comes from the relationships that we form.

As I sit down to take stock of 2013, I realize that it was a great year during which I learned about my family, my career, and myself. During the past year, I have explored challenges that many of us face including the difficulty of achieving balance in life. As I begin 2014, I’m trying to use what I have learned to help me in the year ahead.

As a surgeon, I have incorporated my need for excessive planning and organization into other aspects of my life – sometimes to my detriment. While my lists are important, I have to learn when to put them aside. Some of these changes have been small and have been as simple as not running with my cell phone – being unavailable for one hour is not the worst thing that can happen for me for my patients – or not uploading the data from my Garmin after each run the minute I return home. While these changes are baby steps, they have been huge for me.

I will likely continue to use my lists and in the operating room, but I will also learn to enjoy the relationships that I form with my patients. Sometimes, the key to enjoying it is to throw away the lists and allow the human emotions to show through. Or maybe not….This past weekend, I ran the Houston marathon, and I packed three running watches – all GPS enabled (I actually have four). I nearly panicked when the one that I wore to the race on Sunday morning decided not to work. Then I took a deep breath, and said that I would run based on how I felt, not based on a watch.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the March issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Comparative Analysis of 18-Month Outcomes and Costs of Breast Reconstruction Flap Procedures" by Israeli et al.

Conclusions: 18-month complication and return rates for post-index events were similar across study arms. The frequency of returns and associated cost of procedures unrelated to complications points to the inherently staged nature of autologous breast reconstruction.

The full article will be published with the March 2014 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

As a medical student, I knew an attending who trained decades before and she would tell students how as a resident she kept her marriage a secret because she feared being dismissed. In PRS this month, Ridgway and colleagues report on a survey study highlighting the difficulties that today’s female plastic surgeons have in simply finding someone to marry (“Reflections on the Mating Pool for Women in Plastic Surgery.”).

The authors note that this issue is “not unique to plastic surgery” and the Special Topic article has been made even more topical after the discussion generated this past year in the wake of Sheryl Sandberg’s book, “Lean In,” including this blog where our colleague Dr. Anu Bajaj (http://journals.lww.com/plasreconsurg/blog/PRSonallySpeaking/pages/post.aspx?PostID=185) candidly shared the personal costs and challenges she has faced for “Operating While Female.”

Married to an entrepreneur running a start-up tech company, I’ve been forced to confront a key issue raised by “Lean In”: how to equitably split household and parenting duties with my wife even as we nurture our respective careers. However, Ridgway’s report prompted thoughts not of my wife (who, of course, has already found her ideal mate), but of my two daughters. Having school-age girls nearing all too quickly the cusp of adolescence and who (I hope) will be high-achieving women someday, I wonder about their once unimaginable adult futures: the opportunities that will come their way, the obstacles they will face, and whether they will see both the personal happiness and professional success that all parents wish for children.

My daughters are young enough that I still can’t conceive of their going on dates, let along marrying anyone. But I have developed my own ‘personal strategy’ that I hope will help them someday find a good life partner and a promising career. It’s a simple one (mostly because I can’t think of anything else): I give them my time. Or at least, I try. Although it feels like it’s never enough, I do my best to spend as much time as I can with them, whether it’s to help with homework or just to do something silly and fun. Happily, long gone are the days when spending quality time with your kids meant dealing with questions about your career commitment.

And surgical residents find it more acceptable to openly consider their personal lives. My former attending would be happy to know that the American College of Surgeons website even has suggestions on how to make residency training more “family friendly” (http://www.facs.org/education/rap/sanfey0410.html).

I like to believe I’ll be able to help my daughters navigate this question in the future. What may be a more telling sign of whether my ‘personal strategy’ will work, however, comes when you ask them what they hope to be as grown-ups. Their answers lie in traditionally male-dominated areas: inventor, scientist, engineer, entrepreneur, film and stage director. ‘Surgeon’, however, has not made the list (so far).

Whatever my girls eventually choose, I expect them to be successful at it. And as the father of these future high-achieving women, I admit I’ve become much more sensitive to gender gap issues in the workplace, a characteristic that I apparently share with male corporate executives, at least according to a Wharton professor who cites business studies looking at the impact of infant daughters on their CEO fathers and their management practices (http://www.nytimes.com/2013/07/21/opinion/sunday/why-men-need-women.html?pagewanted=all&_r=0).

And like those fathers, maybe there’s something else besides my ‘personal strategy’ that will help my daughters eventually: what I do when I’m at work away from my daughters may lead to a big impact on their future success, since how surgeons manage and interact with trainees and colleagues sets a tone that permeates out, first in the immediate workplace, but eventually throughout a society. Whether it’s in surgery or business, fathers can play an important role in setting the tone for a professional culture that will determine just how much resistance their own daughters will face if and when they decide to “lean in”.

Over the past four decades, the Consumer Electronics Show (CES) has been a key venue for unveiling the latest technological innovations. The video cassette recorder (VCR) in 1970, compact disc (CD) in 1981, HDTV (1998) and Blu-Ray disc (2003) to name a few all saw debuts at the event. This years show saw a number of wearable technologies, connected devices and 3-D printers emerge, as well as more unusual innovations such as smartphone cases that acted as electric stun guns and thermal imaging cameras.

"Electronics companies have seen the potential in capturing a market that is comfortable with technology, but also in need of healthcare solutions."

This year there was a 40% growth in digital health exhibitors over last year’s show. Wearable devices and fitness trackers were a big presence, with newly announced devices looking to be more functional, and offer ease of use over current offerings. According to the 2014 Accenture Digital Consumer Tech Survey(http://www.accenture.com/SiteCollectionDocuments/PDF/Accenture-Digital-Consumer-Tech-Survey-2014.pdf), 52% of consumers are interested in buying wearable health trackers, and with major companies such as Sony and LG releasing the Sony Core and LG Lifeband Touch respectively, this does not look like a trend that will disappear.

The AARP states that eight in 10 of its members own a computer, tablet, or e-reader, and that 36% of people over the age of 50 are “extremely or very comfortable” with technology. Electronics companies have seen the potential in capturing a market that is comfortable with technology, but also in need of healthcare solutions.

Siemens unveiled the miniTek device that connects the user’s hearing aid via Bluetooth to their phone, tv or other audio device, enabling control of the device via smartphone app (http://youtu.be/UdWfxShoidM).

The catchphrase “I’ve fallen and I can’t get up” , based on the 1980’s commercial is well known, but the latest devices feature automatic fall detection, and operate on a cellular network, offering peace of mind to seniors home and away, relegating that famous phrase to the history books.

For healthcare providers an array of technology providing remote monitoring was unveiled. The Vancive Metria system, uses a disposable patch based wearable sensor, which can detect vital signs, EKG, patient activity and send information to smartphone app or web interface. The Scandu Scout has the appearance of an expensive iPhone accessory, but the function of a gadget from Star Trek. The small handheld scanner connects with the users smartphone to record a series of vital signs (temperature, HR, EKG, pulse ox), saving them to a profile on the accompanying app. The aim of the device is to warn of potential problems or help its owner manage a chronic condition.

From the Plastic surgery perspective, I think that some of these innovations are exciting, and hope that the near future will provide us with better ways to monitor free flaps, view imaging and photographs and interact with our patients.

I look forward to the comments one of our residents makes during Journal Club. They display a clarity of scientific thought; I usually learn something. In the past, I have told him so—in general terms, saying “I really like your comments. They are smart and insightful. Keep it up!” I called that feedback.

Positive feedback seems easier than negative feedback. After all, who doesn’t like to say—or hear—something good? And as I have written in previous posts, our system of feedback is biased toward the positive.

And then, I went to parent-teacher conferences for my own children. “Your daughter is very smart,” one of my children’s teachers told me, “but she’s behind in my class.”

“I know she’s smart,” I told him. “I see that she’s not doing as well as she could on your tests. That’s why I tell her that she’s smart all the time—to boost her confidence.”

—“Being smart is like having big lungs. You can be a runner with big lungs, or you can be a bum with big lungs.”

That, as it turns out, was my problem. I was conflating an inherent characteristic with her work, and that can be confusing for children. Children who are told they are smart are often afraid to try and fail, because they worry that if they do fail, they aren’t smart after all. Instead, child experts say, adults should praise the specific work that they do, and focus on the action. My father used to tell me when I was growing up—and still tells me—“Being smart is like having big lungs. You can be a runner with big lungs, or you can be a bum with big lungs.” I stopped telling my daughter she was smart. I started telling her I was proud of her for studying hard. I praised small decisions she was making about how and when she studied, like setting up a place to work at the dining room table and removing distractions from the area. Her grades improved.

I noticed something else, though. That type of feedback is more challenging to give, precisely because it requires attention to detail and reflection. I had to spend time focusing on what she was doing. I could no longer get away with being vague. Even praising my children for ‘working hard’ is general. What are they doing? How do I know that they are working hard? What part of working hard was a challenge? I must evaluate which decisions they made that were difficult. If my daughter sits at the table studying when the cable is out, it’s very different from her sitting at the table studying when her favorite TV show is on. I pay attention to these details, and bring them up.

Similarly, with the residents, I have found that the most effective positive feedback has that level of detail. Now, I might tell my resident after Journal Club, “I really liked your comment about the stem cell study. You looked up a detail of the protocol and incorporated that into your analysis, and we all learned from that.”

Just as “You weren’t prepared,” is hollow, “You were well prepared” is hollow. “

What’s interesting is that we inherently do this with negative feedback. We are careful to separate out the specific action from the character of the resident. I wouldn’t consider saying to a resident after Journal Club, “You know, I didn’t really enjoy your comments in Journal Club. Frankly, they weren’t that smart or insightful. Do better next time.” I wouldn’t consider that feedback at all—I would consider that an insult. The negative feedback I would give to a resident after Journal Club would have the type of detail and specific behavior often missing from positive feedback. “From your comments in Journal Club, it seemed like you hadn’t read the articles carefully or looked up the statistics that you didn’t know.”

Just as “You weren’t prepared,” is hollow, “You were well prepared” is hollow. “I noticed you struggled to identify the ulnar nerve in the forearm. I think it is probably because you did not know the anatomy,” is how I would give negative feedback. I’d invite the resident to tell me about his experience, and what he thought worked and didn’t. Perhaps he has a good anatomy textbook, but didn’t get a chance to prepare. Perhaps he studied from a textbook that isn’t good for the case we did. It is the resident’s response that then guides my feedback further. That type of interaction provides valuable feedback, because the residents learns where he fell short, and I learn about the resident’s learning process, which helps me become a better teacher for him.

For positive feedback, I also continue the conversation. “I noticed you identified the ulnar nerve in the forearm with ease. It is probably because you knew the anatomy. Tell me how you prepared, and what you think was effective about it.”

I also now ask for specifics about myself. If I am praised for a lecture, I ask what specifically the learner found useful. What I think I did well may be different from what she thinks I did well. We all can learn from feedback.

PRSonally Speaking invites you to discuss controversial or popular papers from the pages of PRS in these periodic blog posts. In order to open the conversation to the entire Plastic Surgery community, the hot topic articles featured as sneak peeks in PRSonally Speaking last month and the articles featured in press releases will be FREE for two months as a special promotion.

Help us get the word out by inviting non-subscriber colleagues, students and residents to read these FREE hot articles and share their comments below.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the February issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Smile Analysis in Rhinoplasty: A Randomized Study for Comparing Resection and Transposition of the Depressor Septi Nasi Muscle" by Arash Beiraghi-Toosi et al.

AbstractBackground: Depressor septi nasi (DSN) muscle is responsible for smiling deformity. Its manipulation is beneficial in patients with muscle hypertrophy. Besides, it enhances the smile and tip-lip relationship. In this study, DSN excision through transfixion incision is compared with its transposition through upper labial sulcus incision.

Methods: Two techniques of DSN treatment were randomly performed for rhinoplasty cases. "Smile analysis in rhinoplasty" consisted of measurements of nasal length, nasal diagonal, tip projection, upper lip height and noting transverse upper labial crease in repose and full smile was performed on preoperative and postoperative photographs.

Results: One hundred patients were studied in two equal groups. Preoperatively, tip projection and upper lip height were significantly decreased with smile. Generally, the effect of smiling on all 5 parameters was significantly decreased following rhinoplasty. The two different techniques were not significantly different in decreasing the effects of smile on nasal length, nasal diagonal, tip projection, upper lip height and transverse crease.

Conclusions: The two different techniques were the same in decreasing the effects of smile. We recommend "smile analysis in rhinoplasty" consisted of measurement of nasal length, nasal diagonal, tip projection, upper lip height and noting transverse upper labial crease in repose and smiling before rhinoplasty for preoperative evaluation and after the operation for outcome assessment. DSN treatment should be considered if decrease in tip projection or upper lip height with smile or a transverse upper labial crease during smile is extraordinary or unsightly.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the February issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Variation in the Incidence of Distal Radius Fractures in the US Elderly as Related to Slippery Weather Conditions" by Chung et al.

AbstractBackground: Distal radius fractures (DRFs) are costly and debilitating injuries, especially for the elderly. DRFs often occur from falls and more commonly occur outdoors. Inclement weather, especially in the winter, may increase the risk of fall-related injuries. Small community studies have reported increased risk of DRF due to inclement winter weather; however, larger studies are lacking.

Methods: We analyzed a sample of 2007 Medicare claims for DRF. Weather data were collected for the date and location of each DRF in our analysis cohort. A novel slipperiness score (0-7, 7 indicates the most slippery weather) was used as a measure of the severity of slippery outdoor conditions. Negative binomial regression models evaluated the correlation between slipperiness and DRF occurrence.

Results: Risk of DRF was higher in winter months (Incidence Rate Ratio=1.2, 95%CI 1.14-1.26, p<0.001). Days with average temperature ≤ 32ºF (IRR=1.36, 95%CI 1.19-1.54, p<0.001), snow/ice on ground at the start of the day (IRR=1.45, 95%CI 1.25-1.68, p<0.001), and freezing rain (IRR=1.24, 95%CI 1.03-1.49, p=0.025) all had an increased risk of DRF. Risk of sustaining a DRF was increased 21% on days with a slipperiness score of 5 or above (IRR=1.21, 95%CI 1.08-1.20, p=0.007). Additionally, for each increase in slipperiness score above 4, the IRR of DRF increased as well.

Conclusions: Weather events that create slippery walking conditions, most often occurring in winter months, result in an increased risk of DRF in the US elderly. This finding can be used to support resource allocation as well as awareness and prevention campaigns.

The full article will be published with the February 2014 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

As you know, PRS produces at least one expert Video Discussion per issue. We love these videos and hope you do too; they provide a dynamic way to make education fun, accessible and multimedia.

We are very thankful for each of our fabulous Video Discussants; their efforts, expertise and willingness to step in front of the camera to discuss our field. They deserve all of our respect and gratitude. Their contributions will be watched for years to come. We could simply not provide the same level of interactivity and multimedia content without them.

While we are asking you to vote for your favorites, and will ultimately crown a "Best Video Discussion of 2013," this title will simply represent the culmination of your opinons. All of the video discussions from 2013 are important, well-done and represent a major time commitment from the surgeons you see on screen. They are all fabulous, interesting and should all be watched!

In the spirit of having a little fun, though, through several rounds of elmination voting, you will choose- by popular vote- the Best Video Discussion of 2013. In order to decide which one to vote for, we encourage you to watch all of them as they each represent hours of research and effort.

Log in, or Register for an account and then Log in, before you vote, and you will automatically be entered in a contest to win an iPad from PRS. If you do not log in with a registered user name, your vote will show up as 'anonymous' and we cannot enter you in the drawing. But, you are still more than welcome to vote to effect the outcome.

Voters will get one ballot entered into the drawing per voting round. There will be THREE voting rounds, meaning each registered user of PRSJournal.com could have three entires in the iPad drawing.

A subscription to PRS is not needed to become a registered user, or to watch the Video Discussions.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the February issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Beyond Biologics: Absorbable Mesh as a Low Cost, Low Complication Sling for Implant-based Breast Reconstruction" by Reish et al.

Purpose: There is an intense push to decrease overall health care costs in the United States. While the use of ADM in implant-based reconstruction has grown significantly over the past decade, there are potential drawbacks that remain a source of debate. ADMs are costly and not universally available across institutions. In contrast, Vicryl mesh is widely available, relatively inexpensive, and resistant to bacteria biofilm formation. With the intent of maximizing the reconstructive and economic advantages of direct to implant-based breast reconstruction, we report the first experience in the literature using an absorbable mesh as an inferolateral sling in direct to implant breast reconstruction.

METHODS: Retrospective review of the first fifty consecutive patients (76 reconstructions) who underwent implant-based breast reconstruction with Vicryl mesh from August 2011 until June 2012.

RESULTS: Fifty patients underwent 76 DTI reconstructions with Vicryl mesh between August 2011 and June 2012, with a mean follow-up of 1.2 years. Five breasts (6.6%) suffered from complications, with only one complication resulting in implant loss (1.3%). Implant positioning and contour were excellent with only two patients (three breasts = 3.9%) undergoing revision procedures which were both for size enlargement. Utilizing costs available at our institution, employing Vicryl mesh instead of ADM resulted in a direct material cost savings of $172,112 USD in ten months.

CONCLUSIONS: Results to date have been encouraging with a low complication rate (6.6%) and excellent aesthetic results. The technique has resulted in $172,112 USD in direct material costs.

Immediate Direct-to-implant breast reconstruction: The Inferior border of the pectoralis muscle is released and the vicryl mesh is sutured into place as an inferior-lateral sling.

The full article will be published with the February 2014 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

PRSonally Speaking invites you to discuss controversial or popular papers from the pages of PRS in these periodic blog posts. In order to open the conversation to the entire Plastic Surgery community, the hot topic articles featured as sneak peeks in PRSonally Speaking last month and the articles featured in press releases will be FREE for two months as a special promotion.

Help us get the word out by inviting non-subscriber colleagues, students and residents to read these FREE hot articles and share their comments below.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the December issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Skin Perforator "Measuring Outcomes that Matter to Facelift Patients: Development and Validation of FACE-Q Appearance Appraisal Scales and Adverse Effects Checklist for the Lower Face and Neck" by Pusic et al.

Background: The FACE-Q is a new patient-reported outcome (PRO) instrument that can be used to evaluate a range of outcomes for patients undergoing any type of facial cosmetic surgery, minimally invasive cosmetic procedure or facial injectable. The aim of this paper is to describe the development and validation of FACE-Q scales relevant to evaluating outcomes in facelift patients.

Methods: The FACE-Q was developed by following international guidelines for PRO instrument development. For outcomes following a facelift we developed five appearance appraisal scales (i.e., Satisfaction with Cheeks; Satisfaction with Lower Face and Jawline; Appraisal of Nasolabial Folds; Appraisal of Area Under the Chin; Appraisal of the Neck) and an adverse effects checklist. A field-test of these scales was performed in a sample of 225 facelift patients and both modern and traditional psychometric tests were used to examine validity, reliability and responsiveness.

Conclusions: The FACE-Q appearance appraisal scales are scientifically sound and clinically meaningful and can be used with the adverse effects checklist to measure PROs following a facelift.

The full article will be published with the December 2013 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

PRSonally Speaking invites you to discuss controversial or popular papers from the pages of PRS in these periodic blog posts. In order to open the conversation to the entire Plastic Surgery community, the hot topic articles featured as sneak peeks in PRSonally Speaking last month and the articles featured in press releases will be FREE for two months as a special promotion.

Help us get the word out by inviting non-subscriber colleagues, students and residents to read these FREE hot articles and share their comments below.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the December issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Skin Perforator "Freeways and Pathways": Understanding the Role of TRUE and CHOKE Anastomoses Between Perforator Angiosomes and their Impact on Skin Flap Planning and Outcomes. Part II: Dynamic Thermographic Identification" by Chubb et al.

BackgroundCadaveric studies have revealed that cutaneous perforators are linked by either reduced calibre "choke" arteries, or by vessels without change in calibre, the "true anastomoses". These true anastomotic vessels are often found in parallel with the cutaneous nerves and accompanying veins, and are associated both experimentally and clinically with larger areas of flap survival. The Doppler probe and CT angiography are already used preoperatively to determine perforator locations, but currently cannot reveal the type of their anastomotic connections.

MethodsThermal images were taken in a previously described fashion, and compared with both CT angiogram studies where available, and with cadaveric angiographic studies previously performed by our laboratory.

ResultsPerforators greater than 1mm in size were accurately localized by thermography when compared with CTA studies. Perforator angiosome rewarming closely approximated a log based line of best fit. Interperforator zones were variable in their rewarming, and correlated with known anatomical patterns of true and choke anastomoses between perforator angiosomes

ConclusionThermography now offers a new modality to bridge the gap by not only identifying the perforator "hot spots" but also the robustness of their interconnections. The pattern ofthese interconnections seen on thermographic

The full article will be published with the December 2013 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

It’s been a while since I have written a blog – life has run away from me. I keep on thinking that things will calm down, but instead, time just goes by faster. However, I have wanted to write this blog for a while – but like other blogs that come from deep within my heart, it has been particularly difficult to write and to focus my thoughts.

Part of my hectic schedule included going to San Diego for the American Society of Plastic Surgeons annual meeting in October.

At the annual meeting, the Women Plastic Surgeons Steering Committee, of which I am chair, hosts a networking lunch – this year, we had a minor catastrophe one month before the luncheon. On a Friday evening a month prior to the meeting I received a call from my staff liaison at ASPS saying that the keynote speaker for our luncheon had to cancel for personal issues. After stressing for 24 hours, I put myself to the grindstone. I resisted my urge to panic and reached out to everyone I knew through phone calls and emails. Fortunately, one of my contacts suggested Natalie Strand. Ultimately, by the end of the weekend, we had a speaker for our luncheon.

Unless you are an Amazing Race fan, you probably are not familiar with Natalie Strand. Natalie Strand is an anesthesiologist who practices in LA. She and her friend, Kat Chang (also an anesthesiologist), were the first female-female team to win the Amazing Race in 2010. During our luncheon, Natalie spoke about winning the Amazing Race, being a female physician, and about teamwork, specifically about how women are unique and can and should work together.

My dad said, “She is like all female surgeons. She has a chip on her shoulder.” My question to him was “what do you mean. I am a female surgeon.”

Part 2

I had said at the beginning of this blog that I have wanted to write this blog for a while. About a month prior to Natalie’s talk, I had read Sheryl Sandburg’s book, Lean In. The book has been somewhat controversial – people either like it or they don’t. And part of the controversy surrounding Sandberg’s book has had to do with how women may contribute to the inequalities we face – by “leaning out.” I have to be honest and say that that the book resonated with me on so many levels because I have been one of those women. As a child and young adult, I had believed it when I was told that “surgery is not a profession for women,” or that I will “not be able to have a family as a surgeon.” And then when I “leaned in” and chose to become a surgeon, I lost my husband and fought against my family along the way.

I remembered the sense of frustration that I felt when I was told to “cut like a man” during residency. I also remembered feeling as if I was ignored -- my chairman would call on me to answer a question, and I would speak. And then he would move to one of the guys who would give the same answer but would be praised for their correct answer instead. I had believed that this was secondary to my inability to communicate effectively and couldn’t understand how to make my answer more clear. I would try short, succinct and to the point; I would try elaborate and detailed. But nothing worked. After reading Sandberg’s book, I realized how people were more likely to remember the responses of men, and I understood.

Sandberg also describes how women in the workplace experience an inverse correlation between “success and likeability.” As I read about this relationship, I remember a comment my father had made two years ago. My nephew had fallen and suffered an open skull fracture and required a craniotomy. His pediatric neurosurgeon was a female. My dad said, “She is like all female surgeons. She has a chip on her shoulder.” My question to him was “what do you mean. I am a female surgeon.” The comment troubled me because I struggle everyday with trying to be friendly and nice but also wanting to be taken seriously. Does this mean that I have a “chip on my shoulder?” It reminded me of the nurse who used to refer to me as “that obnoxious resident” when I was a surgery intern; the same nurse who used to dote over and make cookies for my male colleagues. If you ask any successful woman, I’m sure that she will recount stories about how the same behavior in a successful man is criticized in a successful female. One comment that I received from a scrub tech recently was “you’re not fun.” I really wanted to say, “I’m here to operate.” But instead I was stunned – I thought working in the operating room meant that we were there to take care of the patient.

Part 3

In her book, Sandberg does say that when women deviate from their expected roles, they are more likely to be perceived negatively. She suggests that women should approach conflicts and negotiations communally in an effort to combat this inverse correlation for “success and likeability.” I can understand how I can be perceived as an intense woman who is focused on my job; however, it is my job.

One approach is that when we are at work – in the clinic or in the OR – our first priority is and always should be the patient. Instead of approaching every conflict as an individual, we have to be part of community and not hurt one another because of a perceived threat. The concept of being a part of a team is also why I loved Natalie’s talk -- because it emphasized the concept that we have to help each other to get ahead. As an example, the same year that she and her teammate won the Amazing Race, there were a three other all female teams. Her team and the team that they formed an alliance with came in first and second. The other female-female teams weren’t interested in forming alliances and ultimately lost. Natalie suggested that the while she and her teammate wanted to win, the ultimate goal was for a female-female team to win.

As a group of women, we are more likely to succeed if we each give one another a step up. While we all receive validation by remembering our role in buying into the stereotypes we are placed in, we also have to assume responsibility for overcoming them. While at the meeting in San Diego, I felt that I received my ultimate validation. One of my former attendings has a daughter who is in medical school and would like to become a plastic surgeon. His comment to me was, “I would like her to come and spend some time with you because I think that you would be a good role model.”

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the December issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Skin Perforator "Freeways and Pathways": Understanding the Role of TRUE and CHOKE Anastomoses Between Perforator Angiosomes and their Impact on Skin Flap Planning and Outcomes. Part I: Anatomical Location" by Chubb et al.

Background: Reports of more than 2 cutaneous perforator angiosome territories being raised successfully in distally based sural flaps are appearing in the literature. Previous anatomical studies have noted that cutaneous arteries, connected by true anastomosis without change in calibre, frequently parallel cutaneous nerves.

Method: Twenty four (48 sides) total body lead oxide cadaver injection studies, including 7 arterial and 2 venous neurovascular, were examined and the results compared with clinical thermography in Part II.

Results: Long branches of cutaneous perforators, connected in a series by true anastomoses paralleled at variable distances, the main trunks of cutaneous nerves in the head, neck, torso, upper and lower extremities. Specifically in the leg: an average of 3.2 true anastomoses (range 1 to 5) connected perforators that paralleled the sural nerve on the back of the calf; and 2.5 (range 1 to 4) connected perforators on the medial side of the leg. These vascular freeways were paralleled by the short or long saphenous veins respectively.

Conclusion: True anastomoses frequently connect skin perforators that course in parallel to cutaneous nerves and veins; They provide an explanation for the long viable flaps noted in the leg and it will be shown in Part II that they can be detected preoperatively with thermography.

The full article will be published with the December 2013 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

PRSonally Speaking invites you to discuss controversial or popular papers from the pages of PRS in these periodic blog posts. In order to open the conversation to the entire Plastic Surgery community, the hot topic articles featured as sneak peeks in PRSonally Speaking last month and the articles featured in press releases will be FREE for two months as a special promotion.

Help us get the word out by inviting non-subscriber colleagues, students and residents to read these FREE hot articles and share their comments below.

I read with great interest the article by Nicolas Balague, et al, in the October journal of Plastic and Reconstructive Surgery, “Plastic surgery improves long-term weight control after bariatric surgery”. It is not the first time that researchers have identified that body contouring surgery after massive weight loss results in improved patient outcomes, in this case a sustained and increased reduction in weight. Indeed, the researchers have previously demonstrated that body contouring procedures improved patient-reported outcomes in self-esteem, social life, work ability, physical activity, and sexual activity. It is also well established that a reduction in percentage of body fat reduces insulin resistance and consequent diabetes mellitus, hormonal imbalance, hypertension, sleep apnea, and numerous other comorbidities. In addition, the article was featured in the Wall Street Journal, “Not Just Vanity: Tummy Tucks that Heal.” And in 2012, ASPS statistics show that over 106,000 abdominoplasties were performed.

Given the known health benefits of this procedure, why is it so difficult to get insurers to pay for it? In 2011, the RVU total for a panniculectomy (CPT code 15830) was 17.11, and for the fleur-de-lis add-on code (15847) was “a round number” (i.e., 0). Medicare reimbursement for a panniculectomy in my state is just under $600, when an insurer decides to approve it at all. A 2008 study reported a surgical charge of $3,086 for panniculectomy, with a range of reimbursements from zero to the full amount, with the mean reimbursement of $615 and the median being $899. Contrast this to breast reconstruction. Prior to the Women’s Health and Cancer Rights Act of 1998, breast reconstruction was apparently much more difficult to obtain approval for than at the present time. At the current time, carve-out rates for DIEP flap breast reconstruction are simply jaw-dropping, sometimes in excess of ten times the Medicare rates. This is in the setting of conflicting results regarding the efficacy of the procedure to minimize abdominal wall morbidity.

I do not write this to suggest that DIEP surgery is not superior to TRAM or MS-TRAM breast reconstruction with regard to residual abdominal wall strength. I in fact believe the opposite, specialize in DIEP surgery, and suggest it to nearly all patients who want abdominal-based autologous breast reconstruction. But I raise the point to give an example of what, to me, appears to be an essentially senseless and capricious system of medical reimbursement. I can make XXX dollars for performing a 5 hour DIEP procedure, versus a tenth of that for a 10 hour long mandible reconstruction case for cancer or osteoradionecrosis. Not to mention something like lymphedema. As a microsurgeon, I am intrigued by the results of lymphaticovenous bypass and vascularized lymph node transfer, and interested in offering the procedure to my patients. Certainly patients want the procedure, given the paucity of effective treatment modalities. But I am frustrated by my own (and others’) inability to get insurers to pay for these procedures.

What does this all mean? To me, it is a call to rigorously and quantitatively analyze everything we do. If we can’t measure it, it might as well not be real. Along these lines, I applaud the authors of the cited article, and others performing similar studies to measure patient outcomes (e.g., VTEPS, MROC, BREAST-Q, FACE-Q). Given their example, and the necessity of this work in providing for our future, we should all strive to do the same.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the December issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "The Double Bubble Deformity: Etiology, Prevention and Treatment" by Handel et al.

AbstractBackground: The "double bubble" is a widely recognized complication of breast augmentation but there have been very few articles in the peer-reviewed literature devoted exclusively to this topic.

Methods: Prior publications addressing the anatomy of the inframammary fold (IMF) and its relationship to the double bubble deformity are systematically reviewed. Disagreements among authorities regarding the precise anatomical structure of the IMF are addressed. The etiology and surgical correction of the double bubble are discussed in detail as they relate to the anatomy of the fold.

Results: The key to understanding the causes and correction of the double bubble lies in an appreciation of the anatomy of the IMF. Correction of the deformity varies depending on whether or not patients had pre existing anatomical features predisposing them to development of a double bubble.

Conclusions: A variety of surgical strategies, including use of a dual plane pocket, form stable shaped implants, capsulorrhaphy, pocket plane conversion and use of acellular dermal matrices can play a role in prevention and treatment of the double bubble deformity.

In a type III dual plane pocket, the origins of the pectoralis muscle are divided across the inframammary fold and the retromammary plane is dissected to the superior border of the areola.

The full article will be published with the December 2013 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

The journey from San Diego back to Albany gave me plenty of time to gather my thoughts about the annual meeting. I was honored to be a moderator at the PRS GO resident bowl, and also to give a PRS tech talk on using the iPad. The turnout for my talk was humbling, and made me realize that there are many frequent iPad users who are not aware of many of the device’s features.

The iPad was first released in April 2010, and was a catalyst for the mobile computing revolution. Over 170 million devices have been sold worldwide over the past 42 months. Since the launch, there have been a number o f updates, with the newest iteration unveiled on October 22 2013. As well as the hardware refreshes, there have been 5 different versions of iOS that have been iPad compatible, each with their own features. The current operating system is known as iOS 7.

The first hidden feature I want to discuss is the screenshot function. This allows you to take a picture of what is visible on the device’s screen. This feature is activated by holding down the power button, and then pressing the “Home” button. The screen will flash, and the screenshot will be available in the Photos app.

The screenshot can then be shared, just like any other photograph. I find this feature useful to send screenshots of abstracts and figures from within the PRS app.

The iPad can easily be used for typing if it is placed on a flat surface, but with a full sized iPad, typing with both hands, while holding the device is difficult. The user can compensate by either holding the device in portrait orientation or by typing single handed. Another option is to split the keyboard, into two smaller keyboards, and type with both thumbs. This can be achieved by swiping both thumbs apart on the keyboard, or by holding the keyboard icon in the bottom right of the keyboard. The split keyboard can be moved up and down the screen by touching the keyboard icon and swiping up or down. When the keyboard is split, holding the icon down will enable the user to merge the keyboards. This can also be done by swiping your thumbs together while on the keyboards.

The split keyboards have a series of hidden keys, along the central edges of the keyboards, which correspond to the key across the gap on the other keyboard. Using these hidden keys can allow for faster typing.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the November issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "The Boston Marathon Bombings: The Early Plastic Surgery Experience of One Boston Hospital" by Lin et al.

AbstractBackground: On April 15, 2013 at approximately 2:49 p.m. EDT, two improvised explosive devices detonated near the finish line of the 117th Boston Marathon. Patients were transported from the scene to several trauma centers, including ourinstitution.

Methods: Plastic surgical assessment of patients began in the Emergency Department and then rapidly expanded as the scope of the incident became clear. Daily interdisciplinary meetings involving the Acute Care Surgery, Orthopedic Surgery, Plastic Surgery, and nursing services were convened in order to coordinate operating room schedules and treatment plans. An interdisciplinary weekly clinic continued until all patient goals had been reached.

Results: Twenty-four patients were treated at Beth Israel Deaconess Medical Center (BIDMC) within the first 24 hours of the Boston Marathon bombing. Seven were triaged directly to the operating room from the Emergency Department. The Division of Plastic Surgery was directly involved with the care of eleven patients, all of whom were treated surgically within 24 hours of the bombing. Patients were aged 23 to 50 years old. All eleven patients sustained lower extremity injuries with gross contamination. Four patients also sustained significant upper extremity trauma. Injuries included extremity amputations and fractures; soft tissue loss; impaction of nails and other debris; burns; ocular injury; and ruptured tympanic membranes.

Conclusions: Twenty-four patients received acute care at Beth Israel Deaconess Medical Center following the Boston Marathon Bombing. The institution of dedicated interdisciplinary daily rounds, protected OR block time, and joint follow-up clinic allowed for efficient early diagnosis and treatment of their injuries.

The full article will be published with the November 2013 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

Mersey Burns is a free app for calculating burn area percentages, prescribing fluids using Parkland, background fluids and recording patients' details. It is designed for physicians and runs on iOS, Android, BlackBerry and HTML5 compatible browsers.

This app takes a really simple idea, the use of a Lund & Browder chart to estimate total body surface area of a burn, and uses that information to work out the fluid resuscitation needs.

On opening the app one sees a blank Lund & Browder chart which one shades in for full and partial thickness areas of burn. There are buttons to select for full or partial thickness, erase areas of shading, and to rotate to the posterior view.

Upon completing the area of burn one can input the patient’s age, weight, the time of the burn, and then select a 2ml, 3ml, or 4ml/hr/Kg/%TBSA resuscitation.

The app then calculates the required fluid resuscitation volumes and rates, and for children also calculates the required maintenance fluid requirements.

The app also generates a report which can be emailed for printing/filing purposes.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the November issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Breast Reconstruction Following Nipple Sparing Mastectomy; A Systematic Review of the Literature with Pooled Analysis" by Spear et al.

Introduction: Nipple sparing mastectomy (NSM) is a controversial option for the treatment of breast cancer based upon concern for local regional recurrence and distant metastasis. In addition to these oncologic factors, there are technical factors such as ideal incision type or reconstructive options that are also debatable. This systematic review examines current trends with NSM that includes selection criteria, local-regional and distant metastasis rates, incision choice, and reconstructive options.

Methods: Systematic electronic searches were performed in the Pubmed and Ovid databases using search terms for studies reporting outcomes following NSM and all forms of reconstruction. Studies between 1970 and 2013 were reviewed. Pooled descriptive statistics with separate analyses for incision type and reconstructive method were performed.

Results: A total of 48 studies met inclusion criteria for review yielding 6,615 NSMs for analysis. The overall pooled complication rate was 22%, nipple necrosis rate was 7%, local regional recurrence rate was 1.8%, and distant metastasis rate was 2.2%. Comparing combined patient cohorts for two stage expander to implant, one stage direct to implant, and autologous reconstruction demonstrated overall complication rates of 52.8%, 16.7% and 23.7% and nipple necrosis rate of 4.5%, 4.1% and 17.3% respectively. The various incision types were combined into five categories: radial, periareolar/circumareolar, inframammary, mastopexy and transareaolar with nipple necrosis rates of 8.83%, 17.81%, 9.09%, 4.76% and 81.82% respectively.

Conclusions: Nipple sparing mastectomy appears to be an oncologically safe option for properly selected patients with low rates of local regional and distant metastasis. Overall complication and nipple necrosis rates are affected by incision location and reconstruction method chosen. Randomized controlled trials are warranted to determine best incision and reconstructive method.

The full article will be published with the November 2013 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the November issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Percutaneous Aponeurotomy and Lipo-Filling (PALF) - A Regenerative Alternative to Flap Reconstruction?" by Khouri et al.

Abstract: We present the application of a new approach, Percutaneous Aponeurotomy and Lipo-Filling (PALF), which is a minimally invasive, incisionless alternative to traditional flap reconstructions.

Methods: PALF percutaneously punctures the restrictive subdermal cicatrix and/or endogenous aponeurosis around defects to produce staggered nicks similar to skin graft mesh patterns. Expansion of the restriction by this incisionless process reconstructs the defect and creates a vascularized scaffold with micro-openings that we seed with lipografts. We avoid wide subcision cuts that lead to macrocavities and subsequent graft failure. Postoperatively, we apply a splint to hold open the neomatrix/graft construct in its expansive state until the grafts mature. 31 patients underwent 1-3 PALFs (average 2) for defects that normally require flap tissue transfer: wounds where primary closure was not possible (9), contour defects of the trunk and breast requiring large volume fat grafts (8), burn contractures (5), radiation scars (6), and congenital constriction bands (3).

Results: The regenerated tissue was similar in texture and consistency to the surrounding tissues. Wider meshed areas had greater tissue gain (range 20-30%). There were no significant wound-healing issues, scars, or donor-site morbidities. Advancement tension was relieved without flap undermining or decreased perfusion.

Conclusion: Realizing that, whether scar or endogenous fascia, the subdermal aponeurosis limits tissue stretch and/or its 3-dimensional expansion, we have developed a minimally invasive procedure that expands this cicatrix into a matrix ideally suited for fat micrografts. Grafting this scaffold applies tissue engineering principles to generate the needed tissue and represents a regenerative alternative to reconstructive flap surgery.

The full article will be published with the November 2013 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the November issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Adipose-derived stem cells inhibit the contractile myofibroblast in Dupuytren's disease" by Verhoekx et al.

AbstractBackground: In an attempt to provide minimally invasive treatment for Dupuytren’s disease, percutaneous disruption of the affected tissue followed by lipografting is being trialled. Contractile myofibroblasts drive this fibroproliferative disorder whereas stem cells have recently been implicated in preventing fibrosis. Therefore, we tested the role of stem cells in modulatingmyofibroblast activity in Dupuytren’s disease.

Methods: We compared the effect of co-culturing Dupuytren’s myofibroblasts with either adipose or bone marrow-derived stem cells on isometric force contraction and associated levels of α-SMA mRNA and protein expression. We also tested the effect of these stem cells on Dupuytren’s myofibroblast proliferation and assessed whether this was mediated by cell-cell contact or by aparacrine mechanism.

Conclusion: Adipose-derived stem cells inhibit the contractile myofibroblast in Dupuytren’s disease and these findings lend support to the potential benefit of lipografting in conjunction with aponeurotomy as a novel strategy in thetreatment of Dupuytren’s disease.

The full article will be published with the November 2013 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

“Google is the memory for the new superiority that will take over humanity”Larry Page, Founder of Google.

We co-exist within a universal cyberspace. The language used is the “netspeak” with a “net lingua”. The people that use this language are real people of great diversity, whose output is largely unedited.

From a linguistic point of view this cybernetic language is much like slang, where one must know when and where to use it. From a psychological point of view it should be borne in mind, as the subject we are in contact with, is virtual, but computer technology does influence human behavior in their direction.

Online interlocutors can only retrieve information about each other from the text itself. This may not be an entirely accurate representation of the truth as the medium provides anonymity.

The ability of chatters to graphically express emotions (round faces with eyes, eyebrows and lips) and simulate speech-phonology (phonetic spelling) certainly gives the potential for gestural and linguistically created social-tension to exist. In times where humanity coexists within a technological world, we are used to think that we are shaping technology.

And what about if technology is shaping us?

I was trained with a symbolic communication that made possible translation of ideas in our mind into spoken or written language. Language arrives late because reality is first; language tells us of what already exists; language is interpretation.

So for a symbol (gesture, picture, word, number) to represent an idea, it seems obvious that the idea must have preceded the symbol.

When a symbol is introduced, it must identify something that we can recognize, and it must be agreed upon and remembered before it can become a useful communication tool. With Internet we are transitioning into a communication era where spoken language is vanishing.

Facebook has lead us to share are thoughts through pictures, photos, thumbs up or thumbs down and online profiles. These Internet realities are described with a “post-symbolic language” that is able to cutout the liaison of symbols and instead engender a shared experience.

It was Jaron Zepel Lanier, an American computer scientist that introduced the idea of “post-symbolic communications” in the context of people interacting in a shared virtual world, popularizing the term “virtual reality”, and creating Atari video games, virtual reality goggles, gloves and earphones. In his words, in a virtual world (like in Tron, Matrix or Avatars), a new way of communicating becomes possible, because representation of words can be replaced with instantiated entities that more directly reflect what is meant. Suppose two people who speak different languages are trying to communicate; person A would like to tell person B that “the needle holder broke”; person A cannot tell this to person B using spoken language; as both of them have access to a simulated reality computer terminal, and both put on their goggles, gloves and earphones and find themselves in a public virtual world, person A creates a virtual needle holder and breaks it. Assuming that the context in which it broke was already established (both people knew that somebody broke something), the interaction is largely sufficient to communicate what person A has wished to communicate. This is a “post symbolic communication” because a virtual needle holder is much more like a real needle holder than the sound. In this world, “virtual” tends to be used in reference to things that mimic their “real” equivalents.

In my opinion we must be aware of this form of communication especially if we are beginning to feel we are getting immersed into virtual reality 3D representations and specially when we are training future plastic surgeons that come to us after general surgery, where they have been using the ¨second life virtual world¨ where three 3D virtual reality environments simulate a standard hospital ward, an intensive care unit, and an emergency room with modules that incorporate common surgical scenarios as gastrointestinal bleeding, acute inflammation of the pancreas, and bowel obstruction.

In this second life virtual world, surgical residents of different levels of training, as well as attending surgeons manage virtual patients.

The new plastic surgery resident test us when they tell us that virtual training has shown that the more experience a surgeon has in real life, the better he or she scores in virtual life.

Arturo Prado is an associate professor of plastic and general surgery at the University of Chile School of Medicine.

One of the most important objectives of plastic surgery residents is to practice skills in a safe environment before going into the operating room.

As surgical judgment relies on cognitive and professional skills, it can be better supervised in a simulated operating scenario, enabling trainees to receive feedback about their technical and nontechnical performance.

There are different types of simulators used in plastic surgery:

1. Bench models that are cheap, portable, reusable and have minimal risks with best use in training of basic skills for novice plastic surgeons and that can only measure discrete skills.

These models follow the Fitts-Posner three stage theory of motor skill acquisition and that has a:

1. Cognitive stage in which the trainee intellectualizes the task, with a performance that is erratic in its distinct steps; the best example is with tying a knot, in which the learner must understand the mechanics of the skill, how to hold the tie, how to place the throws, and how to move the hands.

2. Integrative stage in which with practice and feedback, knowledge is translated into appropriate motor behavior; the learner is still thinking about how to move the hands and hold the tie but is able to execute the task more fluidly and with fewer interruptions.

3. Autonomous stage in which practice gradually results in smooth performance; the learner no longer needs to think about how to execute this particular task and can concentrate on other aspects of the procedure.

With these tools we can address the increasingly limited opportunities for technical training and assessment that are offered to residents and fellows, not only during training but also throughout their careers.

It is no longer necessary to educate in a system that relies on chance opportunities for learning new skills.

Simulation allows for risk-free training in technical skills. For the first time, a proficiency-based curriculum can make the actual level of skill rather than a predetermined period of time the primary factor in plastic surgery resident progression up the training ladder, ensuring that patients are cared with expertise in the procedures they perform.

Although simulations alone cannot improve the quality of health care, they do significantly advance clinical education, especially when combined with enriched curricular and educational environments such as virtual operating rooms and lead to enhance clinical reasoning and professionalism.

Arturo Prado is an associate professor of plastic and general surgery at the University of Chile School of Medicine.

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the November issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Outcomes assessment of combination facelift and perioral phenol-croton oil peel" by Zins et al.

Background: Facelift surgery combined with perioral phenol-croton oil peeling is an under-recognized tool for face rejuvenation. The procedure results in significant central face skin tightening as well as wrinkle reduction.

Methods: A retrospective review of 47 consecutive patients who underwent simultaneous facelift and perioral peel was performed. The objective measures used to evaluate appearance change included: (1) a validated patient satisfaction questionnaire, (2) an evaluation of apparent age, (3) an evaluation of perioral wrinkles by independent reviewers using a validated model. Assessment of apparent age was performed as follows: Pre and post operative photographs were randomly shown to 6 reviewers who were asked to estimate the patient`s age. The apparent age was compared to patient`s actual age and reduction in apparent age was calculated. Improvement in perioral rhytids was evaluated by using the Glogau (1-4) scale.

Results: Survey results documented an overall patient satisfaction which was rated as 6.5 on a 1 to 7 scale, with higher scores indicating greater satisfaction. Patients`postoperative apparent age estimate was 8.2 years younger than their real age (p=0.0002). The Glogau score demonstrated a mean reduction of 1.25 (3.3 preoperatively as compared to 1.15 postoperatively, p<0.0001).

Conclusions: Outcomes measurements including patient satisfaction, objective evaluation of wrinkle improvement and significant reduction in apparent age document the power of this technique.

The full article will be published with the November 2013 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

PRSonally Speaking invites you to discuss controversial or popular papers from the pages of PRS in these periodic blog posts. In order to open the conversation to the entire Plastic Surgery community, the hot topic articles featured as sneak peeks in PRSonally Speaking last month and the articles featured in press releases will be FREE for two months as a special promotion.

Help us get the word out by inviting non-subscriber colleagues, students and residents to read these FREE hot articles and share their comments below.

As the mother of a 10-month-old daughter, I’m still trying to figure out how to balance my work and home life. I feel pressure to be everything in both arenas. At work I hear about efficiency, doing more with the same or less, patient-driven access, service. At home I want to be a supportive involved parent and a loving, caring spouse. I feel pulled in many directions and feel like I need Botox just to keep my brows from furrowing all day long. Am I burned out?

Physician burnout seems to be a buzzword as we face the imminent squeeze on the healthcare system when many more Americans will have access to health insurance next year. I was struck by a New York Times article last month, “The Widespread Problem of Physician Burnout” about a recent study published in Archives of Internal Medicine. The medical journal article, “Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population” by TD Shanafelt, MD, et al, states that almost half of the more than 7000 physicians surveyed reported at least one symptom of burnout. Compared to other Americans in the workforce, we as physicians have a statistically significant greater risk of burnout. Another article, “An Interactive Individualized Intervention to Promote Behavioral Change to Increase Personal Well-Being in US Surgeons” from the same lead author in Annals of Surgery, looks specifically at surgeons. Surgeons were found to be poor judges of their well-being as almost 90% rated their well-being as at or above average while over 70% had scores on the Mayo Clinic Physician Well-Being Index that were in the bottom 30%.

What does this mean for plastic surgeons? I think we suffer from burnout as much as our other surgeon colleagues, though we probably do not even know it. Knowing is only the beginning. What can we do about it?

We all struggle with work-life balance. What IS work-life balance? Is there ever balance? It seems to be more of a teeter-totter than a balance. We feel torn between work, families, hobbies, exercise, friends…. As a “caring” profession, we tend to put our patients first and ourselves second. We want to do the best we can for our patients, even if it means staying up all night, skipping that outing with friends, missing Thanksgiving dinner.

In 2014 it is estimated that 30 million or more Americans will have access to health insurance who do not have it today. What will these newly insured people mean for us? More work, less compensation, less time for ourselves. “Efficiency” is another buzzword, along with “technology”. I would argue that “physician well-being” should be as important a buzzword as those. We cannot provide quality medical care to anyone, let alone 30 million more people, if we do not take care of ourselves.

Large HMOs realize this. They have been putting a lot of emphasis on physician health and well-being. I am on the “Physician Health and Well-Being Council” at my facility. There is a lot of effort and money being put toward programs to help physicians fight burnout. Programs are offered to physicians to encourage camaraderie between specialties, to encourage healthy eating, to encourage physical exercise and to encourage mindfulness based stress reduction. For those physicians who do not have access to these opportunities through work, it is important to find ways to address these issues in their own lives. We encourage wellness in our patients, but we need to remind ourselves that we are patients as well. It is becoming more and more important as we become busier and face even more patients in the coming year. The numbers from the studies above are sobering. We need to address burnout together and as individuals more so now than ever.

For me, I am definitely going to take the mindfulness based stress reduction seminar, exercise as much as I can and spend quality time with my family as I watch my daughter grow up. Botox wouldn’t hurt either.

One of the more frequent comparators to surgery is that of the commercial airline industry. This is commonly in the areas of safety, systems management, checklists and regulation.

Worthy and all as most of that stuff is, realistically we all prefer Top Gun to Southwest. Now, through the medium of Google Glass surgery is on the verge of adopting a much more exciting aviation innovation - the HUD, or Head Up Display - definitely cooler than a checklist!

HUD technology has been evolving in military aircraft since initial reflector systems were pioneered pre-World War II. In the 1970s HUD began to be introduced into commercial aircraft and is now available in a number of high-end automobiles.

Google Glass is a wearable computer with an optical head-mounted display (OHMD) which displays information in a smartphone-like hands-free format, that can communicate with the Internet via natural language voice commands. Google Glass has Bluetooth, WiFi, GPS, a 5 megapixel camera, and an HD capable screen that will recreate an image equivalent to 25 inches. It is currently available to an early adopter program for developers and consumers to test Google Glass, and gauge how people will want to use it.

This technology has a number of exciting possible applications for surgeons. Its ability to stream video opens the possibility of real-time mentoring from a remote viewer, ie. an attending supervising a resident operate from the comfort of his office or home whilst being able to offer advise based on exactly what is being seen by the operating surgeon, or to supervise and feedback on a clinical examination remotely.

Utilizing the HUD display during surgery offers even more exciting possibilities to the surgeon, however. The possibility of using the voice activation to call up and scroll through radiology images, pathology reports etc. without taking eyes from the operating field is an appealing one. Other reference material relating to anatomy, operative technique could also be called upon either from the internet or stored on a mobile device paired with Glass. Calling out “Glass, search how to do a rhinoplasty” in the OR may not inspire a lot of confidence though!

Any other potential surgical applications you see for this technology?

At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.

When the article is published in print with the October issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.

This week we present the introduction to "Human flexor tendon tissue engineering: in vivo effects of stem cell reseeding" by Schmitt et al.

Hand injuries such as lacerations and fractures can lead to prolonged disability. More complex injuries involving significant soft tissue loss, open comminuted fractures, and complex tendon injuries have more devastating outcomes and may require multiple surgeries and months to years of rehabilitation (1-4). In the case of significant tendon loss in the upper extremity, tendon autografts (eg. plantaris, palmaris) may be insufficient to meet reconstructive demands. Tissue engineered tendons have shown promise as an alternative tendon source. Additionally, off-the shelf products would decrease morbidity from autograft tendon harvest and decrease operative time due to readily available product in large quantities.

The most critical aspect of any tissue-engineered construct is the scaffold (5). The scaffold must be biologically compatible, favor cell adherence and allow for cell movement within the construct matrix. Ultimately, the scaffold must either become incorporated into the surrounding environment or it must be degraded and replaced by native tissue. Both biologic and synthetic scaffolds have been utilized in research but a viable tendon substitute is not yet widely available for clinical application. Scaffolds can be biologically static, requiring the host to provide all the cells necessary for repair and reintegration, or scaffolds can be “revitalized”, carrying cells and/or growth factors to contribute to, and possibly enhance, the healing process.

After optimization in a rabbit model, recent work in our laboratory has examined the use of human decellularized cadaveric flexor tendon grafts as a scaffold (6-8). We have also shown improved ability to reseed these grafts with fibroblasts afterperacetic acid (PAA) treatment(9). Biomechanical testing demonstrated no significant difference in elastic modulus or tensile strength after PAA treatment. Additionally, there was no decrease in collagen or glycosaminoglycan content (9). Based on these results, we hypothesized that human adipoderived stem cells (ASCs) could be reseeded into decellularized cadaveric human flexor tendon grafts and remain viable in vitro and in vivo over time.

Human ASCs provide several favorable characteristics making them a suitable option for reseeding (10). They are readilyavailable in large quantities by minimally invasive techniques and are multipotent providing the ability to differentiate along multiple cell lineages (11, 12). Because the harvest of ASCs is minimally invasive, they could be used in an autogenous manner with less concern for immunogenicity associated with allogenic stem celltransplantation. Recent data also indicates that the multipotency and proliferative efficiency of ASCs is as effective as MSCs (13-15)and that ASCs can differentiate into tenocytes in vivo (16).

The full article will be published with the October 2013 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

Read is billed as a personalized medical and scientific journal, which is a familiar concept for which those of you using apps like Flipboard or Zite.

Having looked at a stack of unread journals sitting in my office and wondering how I would find the time to discover other articles of interest to me, I was pleased to find this app that could curate articles for me.

One of my practice partners recently introduced me to the app Read by QxMD, and I was impressed by the way the app allowed me to quickly review a selection of articles from a variety of journals, and then e-mail selected articles to colleagues.

Read is a free iOS app (suitable for both iPhone and iPad), available via the App store. Once the app is started for the first time, it will prompt the user to create an account. This allows the user to access their preferences and stored articles across devices. If your affiliated institution is listed, you will be able to use proxy access to download full text pdf files of the articles you want to view, assuming that your institution is a subscriber. During the setup process, you can select which journals to follow from either the A-Z list, or by searching for the name. PRS is one of the listed journals, as well as a number of other plastic surgery journals including specialty journals.

On the iPad, the home screen of the app has a control bar across the top, which allows the user to switch between featured articles, access to the most recent issues of your selected journals, and articles selected based on user defined keywords. The developers of the app state that they use a combination of machine learning, semantic analysis, crowd-sourcing and proprietary algorithms to figure out which articles should be featured for each individual user. Whilst I have found that the system is not perfect, in that I’ve seen several non-relevant articles on my list, I have also discovered several articles that were of great interest which were published in non-plastic surgery journals.

Tapping an article will download the full text pdf to read. The user can then swipe through the pages of the article, and can highlight or underline text, or add notes. By tapping the star icon, the article will be added as one of your favorites. It can be tagged with a keyword for easier retrieval at a later date.Another nice feature is the ability to share the full text article on Facebook, Twitter or via email. If full text access isn’t available it is still possible to share the citation.

In summary, I think that Read is an extremely useful app to access full text articles from a variety of journals, and I’ve found the simple way the app enables me to share and save articles very convenient. I’ve been generally impressed by the how relevant the featured articles have been. Users who do not have institutional full text access will find the app much less helpful.